Nursing Elites

1. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

• A. Decrease intake of fluids after the evening meal.
• B. Drink a glass of cranberry juice every day.
• C. Drink a glass of warm decaffeinated beverage at bedtime.
• D. Consult the healthcare provider about a sleeping pill.

Correct answer: A

Rationale: The correct instruction for the nurse to provide is to advise the client to decrease intake of fluids after the evening meal. By reducing fluid intake before bedtime, the client can minimize the need to void during the night, which can help improve sleep patterns affected by nocturia. Choices B, C, and D are incorrect. Drinking cranberry juice or warm decaffeinated beverage at bedtime may increase fluid intake, exacerbating the nocturia issue. Consulting the healthcare provider about a sleeping pill should not be the first intervention, as it is important to try non-pharmacological approaches first.

2. The healthcare professional is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the healthcare professional to implement?

• A. Stay with the client while the client is standing.
• B. Record the findings on the graphic sheet in the chart.
• C. Keep the blood pressure cuff on the same arm.
• D. Record changes in the client's pulse rate.

Correct answer: A

Rationale: In obtaining a lie-sit-stand blood pressure reading, it is crucial for the healthcare professional to stay with the client while the client is standing. This action is the most important as it ensures client safety during the procedure. Recording findings, keeping the blood pressure cuff on the same arm, and monitoring pulse rate are all important tasks, but staying with the client while standing takes priority to prevent any potential falls or adverse events. By staying with the client, the healthcare professional can promptly address any signs of dizziness or instability, ensuring a safe environment for the client throughout the procedure.

3. When suctioning a tracheostomy, which action is most appropriate for the nurse to take?

• A. Use a sterile tube each time and suction for 30 seconds.
• B. Use sterile technique and turn the suction off as the catheter is introduced.
• C. Use clean technique and suction for 10 seconds.
• D. Discard the catheter at the end of every shift.

Correct answer: B

Rationale: When suctioning a tracheostomy, it is crucial to use sterile technique to prevent infections. Turning off the suction as the catheter is introduced is important to avoid trauma and injury to the tracheal walls. This technique helps maintain the integrity of the tracheostomy site and ensures proper care for the patient.

4. While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?

• A. How will this affect your present sexual activity?
• B. How active is your current sex life?
• C. How has your sex life changed as you have become older?
• D. Tell me about your sexual needs as an older adult.

Correct answer: A

Rationale: Option A is the best response as it directly addresses the client's concern about the reduction in sexual drive caused by the medication. It encourages the client to express their thoughts and feelings about how this side effect may impact their current sexual activity, facilitating open communication and understanding between the nurse and the client. Choices B, C, and D are not as appropriate as they do not directly address the client's immediate concern regarding the impact of the medication on their sexual drive.

5. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

• A. Reassure the client that many obese individuals have concerns about sex.
• B. Remind the client that sexual relationships can be maintained regardless of weight.
• C. Determine the frequency of sexual intercourse.
• D. Ask the client to talk about specific concerns.

Correct answer: D

Rationale: The best response for the nurse is to ask the client to talk about specific concerns. This approach provides an opportunity for the client to express her worries openly, allowing the nurse to gather more detailed information for a comprehensive assessment and to address the client's concerns effectively.

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